A single national formulary – welcome in principle, complex in practice

The first complication is financial. Formularies carry a cost, and every system, whether an integrated care board or an acute trust, has to live within its budget, so decisions are sometimes made with that reality in mind. This challenge was illustrated in CVD with the transfer of a specialist medicine into primary care. Whatever the merits of the medicine, placing it in primary care brought workforce and monitoring commitments that were not fully resourced where the prescribing was expected to happen – creating potential issues for patients in this disease area. A national formulary that moves items to green without following the money relocates the problem.

Harmonising the red, amber and green ratings might seem straightforward, and that much would be welcome. When a secondary or tertiary referral comes into an acute trust, it helps no one if a GP declines to prescribe because the rating in their locality differs from ours. Yet not every system works to three ratings. Some operate an amber plus category, or other variants, so there is no clean national position to align to. Nor can harmonisation be imposed. If a medicine is to be green everywhere, GPs must agree to initiate it, and if it is amber with a shared care protocol or a prescriber information leaflet, agreement has to be reached on that too. None of it can be delivered wholesale without the conversation behind it.

Then there is the formulary itself. If every medicine is simply listed, there is little to distinguish it from the British National Formulary. A formulary has to make choices. The moment national restrictions are placed on what is included, challenge from industry is inevitable. The ABPI has set out its position, welcoming the ambition to speed up equitable access but warning that the formulary must not become a vehicle for cost containment, restrict clinical choice inappropriately, or undermine the plurality of suppliers on which resilient supply chains depend.

The clinical case for rationalisation is nonetheless strong. Take the direct oral anticoagulants, where four agents are in routine UK use. Outcomes across the class are not markedly different, which is what makes rationalisation defensible in the first place. Reducing to two agents then lightens the education burden, since prescribers come to know a smaller number well rather than spreading familiarity across more. That familiarity carries a safety benefit too, since errors are less likely with agents a team uses routinely than with those it reaches for only occasionally. Alongside this sits the need to be clear about first line, second line and third line, so that agents are not reached for too soon. This is where the competing pressures come to roost, with clinical logic pointing one way, commercial interest another, and local budgets underpinning both.

There is a more workable approach, and it already exists within the NHS. National HIV treatment offers a helpful model. The British HIV Association guidelines define the classes and set out which agents are suitable at first line, second line and beyond, with a national prescribing toolkit and cost ranking alongside. What that framework does not do is dictate the single product every clinician must use. Regimens outside the ranked list can still be used where the local multidisciplinary team agrees. The national layer sets out and ranks the suitable agents, and the choice within that is made locally.

That is the structure worth borrowing. Let the national process list the agents suitable for first line, second line and third line in a therapeutic area, then let each system decide which of them it adopts as its own first, second and third line within that national envelope. HIV is specialised commissioning with central funding, so it is the structure I am commending rather than the funding model behind it. It keeps the challenges where they can be managed, at regional level, rather than forcing every difficult trade off up to a national committee blind to local budgets and pathways.

A single national formulary is a goal worth pursuing. Built as one long list, or as a cost saving measure in disguise, it will struggle against the very complexities it is meant to remove. Built as a national framework that sets out the options for first line, second line and beyond while leaving the local choice intact, it can reduce duplication while keeping decisions close to the patients and budgets they affect. That is the version worth working towards.